MEDICARE: JEANNE M WALLACE PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist

General Provider Information

NPI Number	:	1285911032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANNE M WALLACE PHD

Provider Business Mailing Address
First Line	:	1697 EAST 3450 NORTH
Second Line	:
City	:	NORTH LOGAN
State	:	UT
Zip	:	84341
Country	:	US
Telephone Number	:	435-563-0053
Fax Number	:	435-538-8058

Provider Business Practice Location Address
First Line	:	1697 E 3450 N
Second Line	:
City	:	NORTH LOGAN
State	:	UT
Zip	:	84341-8310
Country	:	US
Telephone Number	:	435-563-0053
Fax Number	:	435-538-8058

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2011
Last Update Date	:	11/08/2011

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